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23 May 2011

Questions for Andrew Lansley.

The Guardian is holding a live NHS question time for Andrew Lansley. Here are some questions I would love him to answer.

My questions for Andrew Lansley come from the fact that I live in Stafford, have been a very close observer of the Stafford Hospital story for the last three years, and am aware of the way in which Andrew Lansley has frequently used the Midstaffs Hospital scandal as a way to “demonstrate” the need for radical NHS reform. This is exemplified by the way in which the Stafford Pressure group appeared on his conference platform as an illustration of the "failings" of the NHS.

This falls into a pattern where this government tends to use “exceptional cases” or “headline facts” to illustrate the need for change. Often, as in the case of the yacht story quoted by David Cameron in his "I love the NHS" speech these assertions do not bear close examination

I have put together a brief video which explains some of the misconceptions which lay behind the Stafford hospital story, and indicate the role that Andrew Lansley himself played in giving the story the massive prominence that it received. It is also clear from a detailed study of the press coverage in 2009-2010 that most people would have accepted the findings of the Robert Francis Independent inquiry of 2010 and the recommendations that came from this. The demand for the lengthy and expensive full public inquiry would not have been carried through without the very active support of Andrew Lansley. (I have yet to publish the information on this).

The government is now committed to taking on board the recommendations of the Midstaffs Public Inquiry, which we understand will now continue taking some evidence up to November, and may then spend many months writing its report. The evidence which we are hearing from many different sources has so far completely failed to endorse Andrew Lansley’s vision for the future of the health service. It has also raised many questions about the precise level of "failure" that is represented by Stafford Hospital. Whilst the Inquiry in its months of evidence taking has uncovered some errors, failed opportunities, failures of communication, and deficiencies in training, it has also shown a hospital were many good people were trying very hard to do a good job, often without sufficient resources to do it. It has presented a much more rounded picture of a hospital with its share of problems rather than a uniquely bad hospital.

The Statistical basis for “the case against the hospital” which has been used by Andrew Lansley has been examined in minute detail – though this is never covered by the press – and has been shown to be seriously flawed.

Here are my questions:

The Statistical evidence against Stafford has the characteristic that those who see the statistics at a “granular level” (granular has become a buzz word at the Inquiry) know that they are simply seeing a “signal” which can be confused for a variety of reasons. Those who are operate above the “granular level” have been in this case misled into believing the statistics told them more than they did, often relying on "information" gleaned from the press. Andrew Lansley (and David Cameron) have both referred on a number of occasions to hundreds of unnecessary deaths at Stafford Hospital. How “granular” is his understanding of the Stafford Hospital statistics?

Andrew Lansley's role in Stafford has helped to create the widespread public anxiety that still exists today. Would he like to take the opportunity to reinforce the point made by all the statistical experts that the excess death figures should not be taken at face value?

Andrew Lansley was very strongly in favour of the publication of Hospital Standardised Mortality Rate league table statistics in 2007, and appeared to believe that the use of this kind of statistical information could lead to driving up standards in the health service. The recommendations of the Robert Francis Independent inquiry 2010 led to groups of statisticians working together to devise new and hopefully more reliable systems to monitor hospital performance. We now know that HSMR figures will not be used again in the way that there were in 2007, and that a new “richer” system Summary Hospital-level Mortality Indicator (SHMI). will take its place. The SHMIs will have the virtue that it will be much harder for the press to "over interpret" the figures to mean something that it does not mean. The announcement of these changes has been made very quietly indeed, would Andrew Lansley like to take the opportunity to tell people that the health service has moved away from over simplistic comparisons of death rates at different hospitals?

Andrew Lansley’s reforms lean heavily on local decision making, with a prominent role for the GPs and the Local Health Scrutiny Committees. In the case of Stafford these failed to see any problems at Stafford Hospital, and it is clear that problems did exist, though not on the scale misleadingly indicated by the Dr Foster Figures. Does this give Andrew Lansley confidence that the shift of emphasis to Local decision making will be a sufficient protection for uniformly high quality in the health service?

Andrew Lansley’s reforms of the health service are a major structural re-organisation. It is clear from listening to the evidence of the Stafford Inquiry that the major organisation of 2006-2007, coupled with the financial constraints, and the commercial pressures of moving to Foundation Trust status created the conditions for the problems that did occur. It is also clear form listening to the evidence that the health service has from 2007 onwards been reforming itself organically from within. The PCTs and SHAs did reach the point of having a clearly defined role and having the right people in the right places, though this is already being severely disrupted by the current “reforms”. The SHAs and the CQC have worked quietly and purposefully to devise new better systems for monitoring the NHS, and this has all been done without structural change. The problems that Andrew Lansley saw in 2006-2007 no doubt were real, and were real consequences of the re-organisation, but there are good indications that the Health service has reformed itself very substantially from within. Many people at the Stafford Inquiry have shared their fears that another major top down organisation can only serve to disrupt the delicately balanced working relationships within the NHS. Is Andrew Lansley willing to consider the possibility that major structural reform may not be the best answer for the NHS?

A major part of Andrew Lansleys reforms involves using competition to drive up standards. The evidence of the Inquiry is that competition carries with it a number of negative side effects. A lot of information becomes commercially sensitive, and this militates against transparency. In a situation where hospitals are competing for customers this give disproportionate power to the press, who can make or break a hospital's reputation. In the case of Stafford Hospital it could be argued that the press have behaved in a way which is irresponsible. How does Andrew Lansley intend to ensure that the future press reporting of Health service matters at a local level is carried out in a fair and accurate manner?

Andrew Lansley has committed the Government to listen to the lessons from Stafford. Listening to the evidence it is clear that we are hearing a lot of strong pointers for the reforms that are actually required within the health service. Calling upon the people who have survived the Stafford experience and thought very deeply about what it has to teach us could be a good starting point for reforming the NHS in a well founded way. I would strongly advocate a listening event for those members of the health service who have been involved in the Stafford Story, before any further progress is made on NHS reforms. Is Andrew Lansley willing to consider this?